Simultaneous Gastroscopy and Colonoscopy for the Diagnosis of Gastrojejunocolic Fistula in a 60-Year-Old Man

CASE REPORT 2013 ; 21 (1) : 28-29

Simultaneous gastroscopy and colonoscopy for the diagnosis of gastrojejunocolic fistula in a 60-year-old man

60 yaşında erkek hastada gastrojejunokolik fistül tanısında eş zamanlı gastroskopi ve kolonoskopi

Meltem ERGÜN1, Fatih Oğuz ÖNDER2, Nurgül ŞAŞMAZ2 Department of Gastroenterology, 1 Şişli Etfal Educating and Training Hospital, İstanbul Department of Gastroenterology, 2 Türkiye Yüksek İhtisas Education and Training Hospital, Ankara

Gastrojejunocolic fistula is an unusual, late complication of gastroenteros- Gastrojejunokolik fistül gastroenterostominin nadir ve geç komplikasyonu- tomy. Patients can present with symptoms of a fistula 20 years or more after dur. Hastalık operasyondan 20 yıl sonra bile ortaya çıkabilir. Gastrojejuno- their original gastric surgery. Establishing the diagnosis of gastrojejunocolic kolik fistül tanısı hastalığın nonspesifik semptomatolojisi nedeniyle güçtür. fistula is difficult because it has nonspecific symptoms on admission. The En sık tanı araçları baryumlu grafi ve endoskopidir. Biz gastrojejunokolik most frequently used diagnostic tools are barium enema and endoscopy. We fistülü olan ve tanısını eş zamanlı kolonoskopi ve endoskopi ile koyduğumuz herein report the case of a 60-year-old man with gastrojejunocolic fistula. bir vakayı sunuyoruz. We performed simultaneous gastroscopy and saw the tip of the colonoscope emerging through the gastrojejunostomy stoma. Anahtar Kelimeler: Gastrojejunokolik fistül, gastroenterostomi, kolonoskopi

Keywords: Gastrojejunocolic fistula, gastroenterostomy, colonoscopy

INTRODUCTION Gastrojejunocolic fistula (GJF) is an unusual, late complica- Surgical treatment, a one-stage procedure with revision gas- tion of gastroenterostomy. GJF is generally considered to be trectomy, colonic wedge resection, primary closure of the induced by a stomal ulcer due to inadequate gastric resection, colon, and segmentary jejunal resection, was performed. incompleteness of vagotomy and long afferent loop (1,2). The Restoration of bowel continuity was achieved by gastroenter- most frequent symptoms are upper abdominal pain, severe ostomy and jejunojejunostomy. Unfortunately, the patient’s weight loss, diarrhea, halitosis, and sometimes fecal vomiting clinical condition did not improve after the surgery. Anasto- (3). The diagnosis is most reliably and frequently made by motic leakage was ruled out with methylene blue administra- barium enema and gastroscopy (4,5). The treatment of GJF tion via a nasogastric tube, and there was no leakage through consists mainly of nutritional support with parenteral or en- the drains. Transabdominal ultrasound examination was also teral hyper-alimentation and resective surgery (5).

CASE REPORT A 60-year-old man was referred to our hospital because of severe weight loss (10 kg/1 year), diarrhea, halitosis, and feculent vomiting. His history included a distal gastric resection and Billroth II reconstruction for a duodenal ulcer 20 years previously. The laboratory examinations revealed hypopro- teinemia, hypoalbuminemia and iron deficiency anemia. The colonoscopy demonstrated a large ulcer surrounded by hyperemic fragile mucosa at the transverse colon (Figure 1). Next to the ulcer, a hole was recognized (Figure 2). The colonoscope was inserted through the hole, and the gastroscope was introduced simultaneously (Figure 3). Figure 3 shows the gastroscopic view of the colonoscope in the stomach; the colonoscope had been inserted through the fistula tract from Figure 1. A large ulcer surrounded by hyperemic fragile mucosa at the the transverse colon. transverse colon.

İletişim: Meltem ERGÜN Şişli Etfal Education and Training Hospital, Gastroenterology Department Ergün M, Önder FO, Şaşmaz N. Simultaneous gastroscopy and colonoscopy for the diagnosis Halaskargazi Caddesi Şişli / İstanbul, Türkiye of gastrojejunocolic fistula in a 60-year-old man. Endoscopy Gastrointestinal 2013;21:28-9. Tel: + 90 212 216 83 54 • E-mail: [email protected] Geliş Tarihi: 05.11.2012 Kabul Tarihi: 02.01.2013 29 Simultaneous gastroscopy and colonoscopy

Figure 2. Colonoscopy showed a hole and then mucosal folds resembled Figure 3. Gastroscopic view of the colonoscope in the stomach, which those of the jejunum. had been inserted through the fistula tract from the transverse colon. normal. Pulmonary infiltration was determined, and an an- tal gastrectomy; it occurs in less than 1% if truncal vagotomy tibiotic regimen and respiratory support with endotracheal is included, but in up to 30% of patients with gastroenteros- intubation were performed. However, the patient’s clinical tomy without vagotomy (6,7). Marginal ulcer can be compli- status deteriorated, sepsis developed, and the patient died 7 cated by perforation, hemorrhage and GJF. Diarrhea, weight days after the procedure. loss, halitosis, and feculent vomiting subsequent to gastroenterostomy should call attention to possible GJF. Short-circuit- DISCUSSION ing the length of the small intestine, bacterial overgrowth and colonic bacteria spilling over the entire proximal gastrointes- Gastrojejunocolic fistula (GJF) is a late, severe complication tinal tract were the reasons for the symptoms. Barium enema of a stomal ulcer, which develops as a result of inadequate is the most accurate examination for establishing the diagno- resection of the stomach or incomplete vagotomy (1). As a sis of GJF (8). Esophagogastroduodenoscopy and colonosco- result of the recent development of proton pump inhibitors py are also helpful, not just for the diagnosis but also to rule and Helicobacter pylori eradication regimens for the treat- out any malignant disease. GJF is usually not negotiable with ment of peptic ulcers, the necessity of peptic ulcer surgery endoscopes because of its complex routings. In some cases, has decreased, and the occurrence of GJF has decreased re- like ours, the simultaneous use of two endoscopes clearly markably. However, GJF should be recognized as one of the identified the fistula pathway (9). late severe complications observed after a gastrectomy with In conclusion, GJF, although rare, should be kept in mind Billroth II reconstruction, since this disease may occur even when patients with a history of prior gastrectomy with Bill- 20 years after the first operation for peptic ulcer (2,3). roth II reconstruction suffer from symptoms such as diarrhea Marginal ulcer occurs in 3% of patients post-Billroth II subto- or fecal vomiting and weight loss.

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